Deciplinary Action

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Record of Disciplinary Action

Employee Name:

Employee Title:

Manager Name:

Manager Title:

Todays Date:

Incident Date:

Incident Time:

Incident Location:

1. Description of the incident that occurred:


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2. Witnesses to the incident (if applicable):


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3. Names of those in attendance at current disciplinary action meeting:


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4. Corrective or disciplinary action to be taken:


Verbal

Written

Probation Suspension

Other (explain below)

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(If on probation, period begins ___________________ and ends ___________________.)

5. Goals to be Achieved:
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6. Consequences for failure to improve performance or correct behavior:


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7. Prior discussions or warnings on this subject, whether oral or written:


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8. Employee statement:
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I acknowledge that I have read and understand the above information and consequences.

_______________________________

______________________

Employee Signature

Date

_______________________________

______________________

Supervisor Signature

Date

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